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Consider the Source: A new voice for maternity care reform, J.D. Kleinke

I get a particular kind of delight when I learn about someone who is willing to speak out about U.S. maternity care and yet isn’t the typical stakeholder. You might know the type I’m talking about: not a midwife or a doctor or an activist for any agenda, not someone who was harmed or transformed by their birth, not a spokesperson for a particular agency or professional society – just someone willing to look at our system, intelligently analyze its shortcomings, and be bold about how we could transform it into a system that reliably delivers humane, high-quality care.

A few months ago, I was introduced to J.D. Kleinke. It didn’t take me much time on Google to figure out that J.D. is exactly this kind of non-stakeholder. Turns out he’s a non-stakeholder with tremendous insight and influence. A health economist and health IT pioneer, he’s well known in health care reform and technology circles. He’s also an accomplished and prolific writer, with two health economics text books and articles in just about every major health care publication under his belt. But none of those publications has taken on maternity care specifically – until now. And instead of writing a health economics text, he’s delivered a drama-packed, beautifully crafted novel, Catching Babies, published this month by Fourth Chapter Books. (Disclosure: I received a complimentary review copy.) I know the readers of this blog will be interested in the book. Even more so, I think you’ll be eager to hear more from this new voice for maternity care system reform.

Amy Romano: J.D., in the author’s note at the beginning of Catching Babies, you say that you set out to write a non-fiction collection of case studies addressing conflicts and controversies in the field of women’s health. Instead, you ended up writing a novel about the personal and professional drama of a cadre of ob-gyn residents near the end of their training. How did this process unfold?

J.D. Kleinke: I was living among a group of OB/GYNs as they were going through their residency, right when the non-fiction rudiments of Catching Babies were coming together in my mind. As with many residents in any specialty, they would talk incessantly about their workloads, especially about their weirder cases. As they did, I could not help but notice that the most dramatic and interesting elements of each story were not the specific clinical details, but the emotional reactions of the physicians themselves. Fascination, revulsion, contempt, pathos, cynicism, wonder, ridicule, dread. The wide variety and raw intensity of their responses to what they were dealing with in the hospital every day were often counter-intuitive, sometimes shocking to me, and I noticed how these reactions started to pattern around the personalities and family histories of the physicians themselves. Some OBs tended to respond to the most emotionally difficult cases with fascination and compassion, others with a cynicism or blitheness that bordered on cruelty. After enough watching and listening, I started to notice a strange binomial distribution among the ones I knew most personally: one group were deeply empathic people making enormous sacrifices – they were what we would call heroes and, in a couple cases, martyrs. Another group were cold, mean, vindictive, really nasty – the sort of people who were plenty smart and technically capable – but I wouldn’t want them delivering my dog’s puppies. Oddest of all, there was no middle ground. This is the exact opposite of the bell curve of personality and temperament you tend to find within almost all other groups of professionals, including most other medical, if not surgical, specialties. And people who tend toward the extremes of heroism and callowness make for good drama!

Amy: Your novel begins during the main characters’ final year of residency and ends after they’ve all dispersed into private practice, fellowships, and other post-residency adventures. Why did you choose this particular time frame for your story?

J.D.: Great question. This precise year is the key inflection point in the life of any physician. It’s the moment of truth for everyone leaving years of school and facing their options out there in the big bad world. You’ve been studying, training, amassing debt, living on subsistence wages, and solidifying your ideals for 12 or more years – and now it’s go-time. And your competing choices are hugely different. Are you going to try to cash in as big as you can? Hunker down and try to advance the field? Try to take your already rarefied skills to the next level? Teach? Agitate? Or are you going to endure still another round of academic medicine to help the poor and desperate patients who stream without end into your teaching hospital? This is also the inflection point for doctors personally. Many have been postponing marriage, their own pregnancies, homeownership – in short, all the hallmarks of “growing up” – well into their 30s. And most of the OB/GYNs I’ve observed personally were hellbent on playing catch-up, often making terrible decisions and compromises in the process. This is also ripe for great drama: smart people with some of the most profoundly adult responsibilities in society who are, in a way, still arrested adolescents, thanks to 12 or more years of intense schooling and training.

Amy: One of your characters is an ob-gyn who wants to collaborate with home birth midwives to better integrate care during transfers. Just last month, ACOG released a new Committee Opinion that urges the development of integrated systems to optimize home birth outcomes. What do you see as the major opportunities or barriers when it comes to realizing the vision of integrated systems of care across birth settings?

J.D.: Let the record show – I thought of it first and I have drafts from Catching Babies going back to 2003 to prove it! Actually, it’s an idea whose time has been a long time coming. There is a groundswell of demand among American women to deliver at home – thanks in part to the hair-trigger interventions and often brutalizing processes I portray in Catching Babies – but thanks also to the same ethos emerging around the country regarding green energy, vegetarianism, organic food, recycling, local food sourcing, and generally trying to live a less toxic, less industrialized life – an enormous collective backlash against the technocratization of society. There is a growing number of women who believe that the traditional maternity care system has pathologized childbirth, and they want no part of it. Right or wrong, this is what they believe. There is, therefore, not just an opportunity, but an enormous responsibility for all of us to find ways to cope with their flight to homebirths, because homebirths are going to happen whether we like it or not. The barriers of course are enormous: medical, organizational, financial, legal, even criminal in some situations. Why? Because all elements of what is essentially not a health care system, but is really an “illness care system,” are elemental to the system for profound reasons, most of them ultimately economic. And they will not go away without an especially good fight because, in the home birth setting, the simple fact of the matter is that babies will die – a small number of babies who would not otherwise die had they been delivered in the hospitals, a few feet away from ventilators and the NICU. These cases are of course extreme outliers, as are those babies who die during delivery in the hospital. But we have a better safe than sorry system and culture, and that’s why homebirth will always be fighting a steep uphill battle. I am also just as aware of the thousands of other suboptimal birth outcomes of babies who are rushed through to delivery in the hospital who would have been just fine delivering at home. Unfortunately, the loudest sirens in our society – the lawyers, reporters, and politicians – don’t trade in population statistics, they don’t acknowledge trade-offs. They focus on the outlier, the tragedy of that one dead baby delivered at home – and probably would have died from the same problem in a hospital setting. But still, they focus on the reckless midwife, the random disaster that couldn’t have been prevented anyway. The biggest barrier to homebirth is the difficulty recognizing that the collective outcomes profile for homebirth – delivery complications, infection rates, rates of postpartum depression – is definitely different, and perhaps better for the population as a whole, but it will include an occasional travesty that a hospital setting may have avoided. Would the homebirth family have consented that? Will they honor their waiver of their right to sue? Doesn’t matter. There will always be an ambitious reporter, grandstanding local politician, or gutter-crawling attorney ready to re-write everyone’s intentions, and all the facts, when tragedy strikes.

Amy: You have been called “an advocate for a smarter, data-driven, post-partisan health care system.” What might this look like in the context of maternity care?

J.D.: Smarter and data-driven is easy, or at least easier than the “post-partisan” part! As applied to maternity care, a smarter, data-driven system would be fully armed from end-to-end with good clinical decision support systems specific to pregnancy, labor, delivery, and post-partum care. These systems would mobilize accurate, clinically detailed, risk-adjusted normative data about what works and doesn’t work for a very specific type of pregnancy – actually beginning with pre-pregnancy fertility, genomic and family data – and they would be parsable and analyzable up against accurate, clinically detailed, granular data about the pregnancy at hand. Hard as all that sounds to create and implement, we have now have systems like it in the ICU and for several medical specialties. Why not for maternity care? The “post-partisan” part – well, that is actually harder to imagine – because it would run headlong into much bigger problems than health care system problems. Look no further than the mindless screaming about birth control, abortion, gay marriage, or stem cell research, and you’ll realize that maternity care will never be free from the intrusions of partisan politics. This is actually one of the reasons I find the subject so interesting, and one of the reasons I wrote Catching Babies. Women’s health stands at ground zero for the entrenched ideology, zealotry, fear, and unconscious loathing of women’s sexuality that so clearly enrages many of America’s politicians and preachers. It is what drives people who otherwise claim to be “anti-Big Government” into all of our bedrooms, our marriages, and women’s health clinics, and they are not going to be off minding their own business any time soon.

J.D.: I’m only a novelist – I don’t know if my imagination is that good! Everything that stands between us and that vision are precisely the same things standing between the rest of the American health care mess and a truly reformed, functional system. Maternity care is American health care in miniature, and fixing one on the most fundamental level is as hard as fixing the other. I suppose this is because, ultimately, the problems shared by the two are exactly the same. With childbirth, its just that much more maddening, because pregancy is not a disease, and yet the illness care system presumes that it is, and treats it like it is, and lo and behold, we end up with bad birth outcomes, many of which stem from nothing more than this erroneous orientation. That orientation is wrong in and of itself, whether it’s heart disease, mental illness, or maternity care, but that’s how the non-system was non-designed decades ago, when hospitals were places you went to die, not get better. Consistent with that tradition, our reimbursement is all wrong: providers are paid for more interventions, not better outcomes. And except in a few closed systems like Kaiser or Intermountain – and for only limited periods of time – we have no access to useful patient information, so many birth providers are either going on what the patient was able to report, or they are flying completely blind. What else? The tort system is a disaster and regardless of its actual direct impact, the perception of the size of this impact is caustic, divisive and counterproductive. And the evidence base for some of the most important things in maternity care is not great, and even where the evidence is great, findings are poorly disseminated or ignored. Certain practices are followed by birth providers for years – like the immediate cutting of the umbilical cord postpartum – when common sense and research has shown that delayed cutting is much better for the baby. Nonetheless, providers still do what they always did – because that’s how they always did it. The best ways to realize the vision you’re asking about is to stop treating maternity care – all medical care actually – like a folk art, arm all providers with better information, measure what they do, and radically realign the payment system to reflect those measurements. All else will fall into place. And to answer your last question, the single best way to make all that happen is to arm pregnant women with the same information. This is 2011 – we have the Internet now – no more excuses for paternalistic decision-making on behalf of passive patients. Patients should be encouraged to research and understand their bodies, pregnancies, birth choices, and intervention decision points – without interference, biases, or pressure from providers. Which brings us back to the home birth issue. This is a grassroots rebellion by women who are seeking to take back precisely this kind of control. Maybe they have over-corrected, if only because they felt so little control inside the traditional system, but their actions speak louder about maternity care in America than I ever could!

I’d like to read that book! The idea that physicians are emotionally and socially stunted by their training is completely true in my opinion. Medical students and residents get all the way to 30 years old before they are ever in a situation where they are truly responsible for themselves, often failing to accumulate the life experiences by that time that a person in a less intense training program might have gained by their early 20’s. Not only do I see this in my residents from time to time, but in myself as well.

“This is 2011 – we have the Internet now – no more excuses for paternalistic decision-making on behalf of passive patients. Patients should be encouraged to research and understand their bodies, pregnancies, birth choices, and intervention decision points – without interference, biases, or pressure from providers.”

This is my favorite quote from the interview because I have heard MANY paternalistic MDs claim that no woman without a medical degree should be trusted to make decisions about her own care. I was constantly belittled by my own OB when I asked questions about interventions – which, as I now know, were things I knew more about than he did. Women are still second class citizens in this health care system, and until providers start treating us like we have a brain, I can’t see it getting any better. A woman doesn’t need a medical degree to instinctively know how to give birth, and having a medical degree does not necessarily make a person qualified to actively manage a woman’s labor. It doesn’t matter if you know how to read the machines that go “ping!” if you don’t believe a woman knows how to read her own body.

@Nicholas, I agree with Amy regarding having the author on your podcast.

I started reading “Catching Babies” last week and I’m enjoying it thoroughly. Can’t wait to discuss it with my peers and to assess their opinions. The underlying concern that the residency training process results in unexamined blind spots is (in my opinion) an unassailable fact. The question of course; is how do we change the training process so that future doctors can overcome these problems.

My personal bias is that exposure to childbirth as a normal phenomenon rather than a series of crises would be an important component to this type of education; I’m anxious to see what Mr. Kleine’s conclusions are.

Chuck, I would love to read a more comprehensive take from you (just whip it up in all of your free time, okay?) about how what you are witnessing currently in education training varies from what you observed/experienced when you began. You’ve been one of few who addresses high cesarean rates among residents (75%-ish, I think you’ve said).

A bunch of birth professionals in Massachusetts were recently wondering some things about OB/GYN training. For example, what percentage of OB residents get to experience attending to a woman for the COMPLETE cycle of labor and delivery starting in early labor, ever? The OB’s I’ve talked to have indicated that they may go through their entire training without seeing a full process of normal birth including labor. Perhaps this is one place to think about OB training… Can’t wait to read this book! Great interview.

A huge part of the problem in implementing reform is that we have a revenue-driven health care system (not, BTW, a problem unique to maternity care, as my husband’s long career in the cancer radiation therapy business has taught me). From everyone’s point of view, except the mother’s and the baby’s, the ideal delivery is a cesarean, preferably a planned cesarean. On the obstetrician’s side, it usually pays somewhat more than vaginal birth http://www.childbirthconnection.org/article.asp?ck=10647, but, more importantly, it allows for time management, and time is money. On the hospital side, cesarean surgery ensures use of anesthesia services; increases billable services, procedures, and drugs; and lengthens postpartum stay–all of which increase revenue http://www.childbirthconnection.org/article.asp?ck=10647–and scheduled surgery allows for planning staffing, which reduces overhead. Economics also promotes use of practices that increase the cesarean rate such as labor induction and continuous electronic fetal monitoring. All of this creates enormous subconscious pressure to justify maintaining the status quo. Unless we do something about the economic disincentives, I see little hope of meaningful reform.

Cynthia :
A bunch of birth professionals in Massachusetts were recently wondering some things about OB/GYN training. For example, what percentage of OB residents get to experience attending to a woman for the COMPLETE cycle of labor and delivery starting in early labor, ever? The OB’s I’ve talked to have indicated that they may go through their entire training without seeing a full process of normal birth including labor. Perhaps this is one place to think about OB training… Can’t wait to read this book! Great interview.

Interestingly, a wonderful family doctor I work with, who has been working in low-risk maternity care for a few years and probably has caught upwards of 1000 babies, recently supported a good friend through a long labour and birth. She was full of wonder and awe at her friend’s strength. She mentioned how different an experience it was to have been with her friend for the entire thing, including the time at home. Turns out, this was the FIRST time ever she had seen labour and birth from start to finish…
Changing the training system, so that seeing the entire thing straight through is one of the FIRST birth experiences a doc has, would go a long way I think.

@Jill: I’m on it!
@Henci: I absolutely agree with your analysis of the current economic analysis of incentives that favor expedited, “efficient” and cost effective maternity care at the expense of what may be in the best interest of the mother and infant. Unfortunately, a major problem among practitioners and participants in the current system is that they do not realize the shortcomings of this approach and the fact that short term financial gains are being (more than) offset by long term considerations (maternal morbidity, neonatal adverse outcome, time and expense for future medical problems, etc.). You know…. the kind of stuff that is written about on sites like Science and Sensibility… : )

The educational process needs to start early (medical school rather than residency). Experiences during residency need to focus on the potential down-sides of over-intervention. Heck, intervention period. And as others have stated here; patient’s need to feel empowered to question the nature of the care they are getting. As one who deals with residents I can vouch for the fact that each component is daunting; but it has to be done. I’m hoping that discussions like this will start the needed sea change.

Having so clearly delineated the BIG issues – maternity care nested in the illness business, habit as the basis of practice, women’s bodies as a source of turf battles (politics), emerging care providers who have never seen the course of a natural labor, and young women who can see through the crazy-quilt of intrusion into a key life experience – I am hoping that Kleinke will next encourage (perhaps too mild a word) updating a system that views women’s bodies as a tool. I want to push for more awareness of the evidence about physical fitness in the childbearing process. Of course, it starts well before conception and continues into the postpartum period. Why would anyone think women will tolerate pregnancy, birth and parenting without body trust, knowledge and physical prowess?

I completely agree with what you are saying, but one problem that I see is the training of residents in high-risk OB procedures. If we could transform OB care so that physiologic birth was the norm, the need for high-risk procedures would decrease significantly. With an already-reduced schedule of hours worked, how long would residency have to be in order to give residents enough experience with high-risk management and surgery?

Collaboration with a homebirth midwife? Got you beat J.D.! We’ve been doing that full time for 15 years in our practice. I’ve worked side by side with OB/Gyn Josè Luis Grefnes ever since I asked him to accompany me at the birth of a VBAC mom in 1995. As a physician he had access to and could utilize a little charity hospital. The woman I’d been consulting with for 7 months realized that we wouldn’t be “allowed” to birth vaginally in the free governmental hospital where I was working and she didn’t have the economic resources for a caregiver or a hospital that charged. We went looking for an alternative and it was an open minded and open hearted and altruistic OB. We joined our talents to attend her birth (and her three subsequent VBACS, the most recent which was in 2009.) Incidentally as her economic situation improved she was able to pay for our care and her three waterbirths were all in our birth center).
This is not just a “one off” situation either. Three years ago a doctor invited me to attend his daughter’s homebirth. We met for a weekend seminar in his home and reviewed videos and photos from births we had each attended. His own grandson was the first birth he ever attended with the mother birthing on all fours.
Over the years I’ve had three MD (one was an OB/Gyn) come to my home
for 2 and 3 week stays during which they shadowed this childbirth educator/doula/midwife for a true “post doc” program! All are now attending homebirths. The OB Gyn has gone on to homebirth herself.
Looking foward to meeting you tomorrow in Cardiff by the Sea. Both Amy and Jill’s interviews have inspired me to read your book (which just arrived by mail) by then!

Several doctors and former labor and delivery nurses have recommended to their children that they give birth at the Farm Midwifery Center. This is a trend that we began to see about ten years ago; it’s getting stronger.

@Henci Goer
Henci is right on about there being incentives to cesarean. I think these are not so much the actual reimbursement from the procedure, but more the secondary gain in being able to better cover one’s office practice and protect one’s personal time.

I have often wondered if it were possible to care for each laboring woman in a vacuum, completely separated from any outside influence. This would seem to be the ideal, and many midwives and homebirth advocates suggest that this is what they provide – but if we wanted to do this, would we actually have the resources required? Today’s medicalized birth system is in many ways an efficient product that allows care to be delivered to a massive number of women with relatively fewer people than would be required if each one were care for by a single person, dedicated to their entire labor.

I see the appeal of such a system, but am not sure it could exist without massive change in the system, perhaps an impossible change. Are there really that many people in the world that want to be midwives?